Unplanned Hospital Readmissions and Reoperations After Pediatric Spinal Fusion Surgery

High inpatient-opioid consumption predicts extended length of hospital stay in patients undergoing spinal fusion for adolescent idiopathic scoliosis

OBJECTIVES

Opioids are common medications used following spine surgery. However, few studies have assessed the impact of increased inpatient-opioid consumption on outcomes following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The aim of this study was to determine the impact of increased inpatient-opioid consumption on hospital length of stay (LOS) following PSF for AIS.

METHODS

A retrospective cohort study was performed using the Premier Healthcare Database (2016-2017). Adolescent patients (11-17 years old) who underwent PSF for AIS, identified using ICD-10-CM coding, were stratified by inpatient MME (morphine milligram equivalent) consumption into Low (< 25th percentile for the cohort), Medium (25-75th percentile), and High (> 75th percentile) cohorts. Demographics, comorbidities, intraoperative procedures, perioperative adverse events (AEs), length of hospital stay (LOS), non-routine discharge rates, cost of admission, and 30-day readmission rates were assessed. A logistic multivariate regression analysis was performed to determine the association between inpatient MME consumption and extended LOS.

RESULTS

Of the 1042 study patients, 260 (24.9%) had Low-MME consumption, 523 (50.2%) had Medium-MME consumption, and 259 (24.9%) had High-MME consumption. A greater proportion of patients in the High cohort identified as non-Hispanic white (Low: 46.5% vs Medium: 61.4% vs High: 65.3%, p < 0.001), while the proportion of patients reporting any comorbidity did not vary across the cohorts (p = 0.940). The number of post-operative AEs experienced also did not vary across the cohorts (p = 0.629). A greater proportion of patients in the High cohort had an extended LOS (Low: 6.5% vs Medium: 8.6% vs High: 19.7%, p < 0.001), while a greater proportion of patients in the Low cohort had an increased cost of admission (Low: 33.1% vs Medium: 20.3% vs High: 26.6%, p < 0.001). The High cohort had increased 30-day readmission rates relative to the Low and Medium cohorts (Low: 0.8% vs Medium: 0.2% vs High: 1.5%, p = 0.049). Non-routine discharge rates did not vary among the cohorts (p = 0.441). On multivariate analysis, High-MME consumption was significantly associated with extended LOS, while Medium-MME consumption was not [Medium: aOR: 1.48, CI (0.83, 2.74), p = 0.193; High: aOR: 4.43, CI (2.47, 8.31), p < 0.001].

CONCLUSIONS

Our study showed that high post-operative-MME consumption was significantly associated with extended LOS in patients undergoing PSF for AIS. In light of these findings, changes to existing protocols that decrease the reliance on opioids for post-operative analgesia are merited to improve patient outcomes and reduce health-care expenditures.

Long-term reoperation rates following spinal fusion for neuromuscular scoliosis in nonambulatory patients with cerebral palsy

PURPOSE

To describe the incidence of reoperation and factors contributing to surgical revision within a minimum of 10 years after spinal fusion for scoliosis in patients with nonambulatory cerebral palsy (CP).

METHODS

We conducted a retrospective review of consecutive nonambulatory patients with CP who underwent primary spinal fusion at a single specialty care center with a minimum of 10 years from their index surgery (surgery dates 2001-2011). Causes of reoperation were classified as implant failure/pseudoarthrosis, surgical site infection (SSI), proximal junctional kyphosis, prominent/symptomatic implants, and implant removal. Reoperation rates with 95% confidence intervals were calculated for each time interval, and an actuarial survival curve was generated.

RESULTS

144 patients met inclusion criteria (mean age = 14.3 ± 2.6 years, 62.5% male); 85.4% had 5 years follow-up data; and 66.0% had 10 years follow-up data. Estimates from the actuarial analysis suggest that 14.9% (95% CI: 10.0-22.0) underwent reoperation by 5 years postsurgery, and 21.7% (95% CI: 15.4-30.1) underwent reoperation by 10 years postsurgery. The most common causes for reoperation were implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants.

CONCLUSIONS

To our knowledge, this study is the largest long-term follow-up of nonambulatory patients with CP and neuromuscular scoliosis who underwent spinal fusion. Approximately 22% of these patients required reoperation 10 years after their index surgery, primarily due to implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. Complications and reoperations continued throughout the 10 years period after index surgery, reinforcing the need for long-term follow-up as these patients transition into adulthood.

LEVEL OF EVIDENCE

III.

Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis

INTRODUCTION

Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion.

METHOD

A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0).

RESULTS

25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries.

CONCLUSION

Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.

Risk factors for unplanned readmissions in paediatric neurosurgery: a systematic review protocol

INTRODUCTION

Unplanned hospital readmission (UHR) following surgical procedures reflects patient outcomes. While adult readmission studies are abundant, limited research exists in paediatric populations, especially in the context of neurosurgery.

METHODS AND ANALYSIS

This protocol outlines a systematic review aimed at identifying reasons for unplanned readmissions (30-day and 90-day readmissions) and risk factors following paediatric neurosurgical procedures. Narrative synthesis, sensitivity analyses, subgroup analyses, and meta-analysis, when appropriate, will be done.

ETHICS AND DISSEMINATION

There are no primary data involved and no access to confidential patient information. The findings aim to contribute to refining clinical practice, enhance patient counselling, and optimise healthcare resource utilisation in paediatric neurosurgical care.

PROSPERO REGISTRATION NUMBER

CRD42023455779.

30-and 90-day readmissions in lumbar spine surgery. Differences in prevalence and causes

BACKGROUND

The morbidity associated with surgical treatment of lumbar degenerative conditions has attracted increasing interest due to the economic impact on society, especially postoperative readmission. Limited studies have assessed this risk in a prospective, single-center consecutive fashion.

OBJECTIVE

To assess the incidence and causes of 30- and 90-day unplanned readmission and revision surgery following surgical treatment for lumbar degenerative spine conditions at a tertiary treatment center.

STUDY DESIGN

Prospective, single-center cohort study.

METHODS

All patients undergoing degenerative lumbar spine surgery in a 1-year period from February 1st, 2016, were prospectively included. Patient characteristics, surgical information and information regarding postoperative complications, including readmission (30- and 90-days) and revision surgery were recorded. Readmissions were classified according to whether they were due to the surgical intervention specifically, or a medical complication.

RESULTS

A total of 1399 patients underwent surgery for various lumbar degenerative pathologies in the study period and all were included. Of these, 9.4% (n = 132) were readmitted within 30 days of surgery and in some cases, multiple readmissions occurred (up to 3). The total 90-day readmission rate was 17.6%. Of these, 15% were related to the surgical procedure. The predominant medical related causes were systemic infection (30-day: 14.4%, 90-day: 10.7%), neurological symptoms (30-day: 6.3%, 90-day: 5.0%) and cardiovascular events (30-day: 8.1%, 90-day: 12.9%). The surgical related causes for readmission were pain (30-day: 13.1%, 90-day: 2.9%), wound complications (30-day: 11.3%, 90-day: 5.0% and re-herniation (30-day: 13.1%, 90-day: 2.9%). Age was the only factor with significant influence on readmission.

CONCLUSION

The incidence of medical conditions causing unplanned 30-day readmissions following surgery for lumbar degenerative conditions, is significantly higher compared to readmissions related specifically to the surgical procedure. Examples of medical treatment included antibiotics, analgesics, laxatives, anticoagulants and beta blockers. The difference is even more pronounced for the 90-day readmissions. The predominant medical causes were systemic infections, neurological and cardiovascular events. Predominant causes related to the surgery were pain, wound complications and re-herniations. Readmissions may be reduced by optimizing the medical treatment and the pain management before discharge of the patient.

Use of monopolar cautery in patient with a vagal nerve stimulator during neuromuscular scoliosis surgery

It is a historic and common practice while performing spine surgery on patients with a VNS has been to have the patient's neurologist turn off the VNS generator in the pre-operative anesthetic care unit and to use bipolar rather than monopolar electrocautery. Here we report a case of a 16-year-old male patient with cerebral palsy and refractory epilepsy managed with an implanted VNS who had scoliosis surgery (and subsequent hip surgery) conducted with the use of monopolar cautery. Although VNS manufacturer guidelines suggest that monopolar cautery should be avoided, perioperative care providers should consider its selective use in high-risk instances (with greater risks of morbidity and mortality due to blood loss which outweigh the risk of surgical re-insertion of a VNS) such as cardiac or major orthopedic surgery. Considering the number of patients with VNS devices presenting for major orthopedic surgery is increasing, it is important to have an approach and strategy for perioperative management of VNS devices.

Friends Not Foes: Optimizing Collaboration with Subspecialists

Pediatric orthopedic patients can be complex to manage. As orthopedists plan for possible surgical interventions, consultation with pediatric subspecialists will be necessary. This article discusses the considerations an orthopedist should make when deciding on the timing and the appropriateness of consultation-both preoperatively and perioperatively. Consultation before surgical intervention will especially be useful if the subspecialist will be collaborating in the management of the condition postoperatively (whether inpatient or outpatient). Clear and early consultation in both written and verbal format will facilitate quality and expedite the patient's care.

Incidences, causes and risk factors of unplanned reoperation within 30 days of craniovertebral junction surgery: a single-center experience

PURPOSE

To investigate the incidences, causes, and risk factors for unplanned reoperation within 30 days of craniovertebral junction (CVJ) surgery.

METHODS

From January 2002 to December 2018, a retrospective analysis of patients who underwent CVJ surgery at our institution was conducted. The demographics, history of the disease, medical diagnosis, approach and type of operation, surgery duration, blood loss, and complications were recorded. Patients were divided into the no-reoperation group and the unplanned reoperations group. Comparison between two groups in noted parameters was analyzed to identify the prevalence and risk factors of unplanned revision and a binary logistic regression was performed to confirm the risk factors.

RESULTS

Of 2149 patients included, 34(1.58%) required unplanned reoperation after the initial surgery. The causes for unplanned reoperation contained wound infection, neurologic deficit, improper screw placement, internal fixation loosens, dysphagia, cerebrospinal fluid leakage, and posterior fossa epidural hematomas. No statistical difference was found in demographics between two groups (P > 0.05). The incidence of reoperation of OCF was significantly higher than that of posterior C1-2 fusion (P = 0.002). In terms of diagnosis, the reoperation rate of CVJ tumor patients was significantly higher than that of malformation patients, degenerative disease patients, trauma patients, and other patients (P = 0.043). The binary logistic regression confirmed that different disease, fusion segment (posterior) and surgery time were independent risk factors.

CONCLUSIONS

The unplanned reoperation rate of CVJ surgery was 1.58% and the major causes were implant-related failures and wound infection. Patients with posterior occipitocervical fusion or diagnosed with CVJ tumors had an increased risk of unplanned reoperation.

Risk factors for 90-day readmission and prolonged length of stay after hip surgery in children with cerebral palsy

Objective

Spastic hip dysplasia is a common complication of cerebral palsy in children, and surgical intervention is usually warranted. While current literature has primarily analyzed single institution outcomes, this study utilized a national database to describe readmission rates and factors correlated with readmission for children with cerebral palsy undergoing hip surgery in order to treat this population more effectively.

Methods

This study queried the Nationwide Readmissions Database (2014-2018) for pediatric patients with cerebral palsy who underwent hip surgery. Patient demographics, pre-operative comorbidities, length of stay (LOS), treatment complications, and readmission data were collected for each patient and analyzed with inferential statistics.

Results

Of the 1225 patients included, the average age was 9.3 ± 3.8 years and 42.8% were female. Approximately 26.3% patients had a prolonged LOS (≥5 days) and 14.2% patients required readmission within 90-days of surgery. Medical complications, cardiac arrhythmias, and iron deficiency anemia were all significantly associated with elongated LOS as well as 90-day readmission. Patients with Medicaid were more frequently associated with an inpatient medical complication and the overall complication rate was 5.5%.

Conclusions

While current literature has analyzed common risk factors and complications associated with hip surgery in the pediatric cerebral palsy patient, this study identifies a national readmission rate (14.2%) as well as preoperative comorbidities associated with readmission within 90-days and/or elongated LOS. Notably, complications are more frequently associated with patients using Medicaid. These results further exemplify the importance of equitable access to care and thorough selection of pediatric cerebral palsy patients appropriate for hip surgery.

Thirty-day unplanned reoperations of thoracic spine surgery: 10 years of data from a single center with 3,242 patients

BACKGROUND CONTEXT

Unplanned reoperation is a useful quality indicator for spine surgery. However, the rates of a 30-day unplanned reoperation in patients undergoing thoracic spinal surgery are not well established.

PURPOSE

To assess the rates, reasons, and risk factors of 30-day unplanned reoperations for thoracic spine surgeries in a single center study.

STUDY DESIGN

A retrospective observational study.

PATIENT SAMPLE

3,242 patients who underwent thoracic spinal surgery at our institution in the past decade were included.

OUTCOME MEASURES

The incidence, chief reasons, and risk factors for unplanned reoperations within 30 days after thoracic spinal surgery.

METHODS

We retrospectively analyzed the data of all patients who underwent thoracic spinal surgery between January 2012 and December 2021. Statistical methods, including univariate and multivariate analyses, were performed to assess the incidence, reasons, and risk factors for thoracic degenerative diseases, spinal tumors, kyphosis deformity, and spinal trauma.

RESULTS

Of the 3,242 patients who underwent thoracic spinal surgery, 107 (3.30%) required unplanned reoperations within 30 days due to epidural hematoma (1.17%), wound complications (0.80%), implant complications (0.43%), inadequate decompression (0.25%), and other causes (0.65%). Patients with degenerative disease (3.88%), spinal tumor (2.98%), and kyphosis deformity (3.33%) had significantly higher incidences of reoperation than those with spinal trauma (1.47%). Unplanned reoperations were classified as hyperacute (30.84%), acute (31.76%), and subacute (37.38%). After univariate analysis, several factors were associated with unplanned reoperation in the 4 cohorts of thoracic spine diseases (p<.05). Multivariate logistic regression analysis revealed that upper thoracic spine surgery (p=.001), concomitant dekyphosis (p=.027), and longer activated partial thromboplastin time (p=.025) were risk factors of unplanned reoperation for thoracic degenerative disease. Whereas American Society of Anesthesiologists (ASA) grade III (p=.015), combined approach (p=.016), and operation time longer than 420 min (p=.042) for spinal tumor, and similar ankylosing spondylitis (p=.023) and operation time longer than 340 min (p=.041) were risk factors of unplanned reoperation for kyphosis deformity.

CONCLUSIONS

The unplanned reoperation rate for thoracic spine surgery was 3.30%, with epidural hematoma and wound complications being the most common reasons. However, upper thoracic spine surgery, concomitant dekyphosis, underlying coagulation disorder, longer operation time, higher ASA grade, and comorbidities of ankylosing spondylitis led to an increased risk of unplanned reoperation within 30 days of thoracic spine surgery.

Incidences, causes and risk factors of unplanned reoperations within 30 days of spine surgery: a single-center study based on 35,246 patients

BACKGROUND CONTEXT

Unplanned reoperation, a quality indicator in spine surgery, has not been sufficiently investigated in a large-scale, single-center study.

PURPOSE

To assess the incidences, causes, and risk factors of unplanned reoperations within 30 days of spine surgeries in a single-center study.

STUDY DESIGN

Retrospective observational study.

PATIENT SAMPLE

A cohort of 35,246 patients who underwent spinal surgery in our hospital were included.

OUTCOME MEASURES

The rates, chief reasons, and risk factors for unplanned reoperations within 30 days of spine surgery.

METHODS

We retrospectively analyzed the data for patients who underwent spine surgeries for degenerative spinal disorders, tumor, or deformity and had subsequent unplanned operations within 30 days at a single tertiary academic hospital from January 2016 to July 2021. Univariate and multivariate analyses were performed to assess the incidences, causes, and risk factors.

RESULTS

Out of 35,246 spinal surgery patients, 297 (0.84%) required unplanned reoperations within 30 days of spine surgery. Patients with a thoracic degenerative disease (3.23%), spinal tumor (1.63%), and spinal deformity (1.50%) had significantly higher rates of reoperation than those with atlantoaxial (0.61%), cervical (0.65%), and lumbar (0.82%) degenerative disease. The common causes for reoperation included epidural hematoma (0.403%), wound infections (0.148%), neurological deficit (0.108%), and pedicle screw malposition (0.077%). Unplanned reoperations were classified as hyperacute (45.45%), acute (30.98%), subacute (15.82%), or chronic (7.74%). Univariate analysis indicated that 20 clinical factors were associated with unplanned reoperation (p<.05). Multivariate Poisson regression analysis revealed that anemia (p<.001), osteoporosis (p=.048), ankylosing spondylitis (p=.008), preoperative foot drop (p=.011), deep venous thrombosis (p<.001), and previous surgical history (p<.001) were independent risk factors for unplanned spinal reoperation.

CONCLUSIONS

The incidence of unplanned spinal reoperations was 0.84%. The chief common causes were epidural hematoma, wound infections, neurological deficit, and pedicle screw malposition. Anemia, osteoporosis, ankylosing spondylitis, preoperative foot drop, deep venous thrombosis, and previous surgical history led to an increased risk of unplanned reoperation within 30 days of spine surgery.

A novel risk calculator predicting surgical site infection after spinal surgery in patients with cerebral palsy

AIM

To develop and validate a risk calculator based on preoperative factors to predict the probability of surgical site infection (SSI) in patients with cerebral palsy (CP) undergoing spinal surgery.

METHOD

This was a multicenter retrospective cohort study of pediatric patients with CP who underwent spinal fusion. In the development stage, preoperative known factors were collected, and a risk calculator was developed by comparing multiple models and choosing the model with the highest discrimination and calibration abilities. This model was then tested with a separate population in the validation stage.

RESULTS

Among the 255 patients in the development stage, risk of SSI was 11%. A final prediction model included non-ambulatory status (odds ratio [OR] 4.0), diaper dependence (OR 2.5), age younger than 12 years (OR 2.5), major coronal curve magnitude greater than 90° (OR 1.3), behavioral disorder/delay (OR 1.3), and revision surgery (OR 1.3) as risk factors. This model had a predictive ability of 73.4% for SSI, along with excellent calibration ability (p = 0.878). Among the 390 patients in the validation stage, risk of SSI was 8.2%. The discrimination of the model in the validation phase was 0.743 and calibration was p = 0.435, indicating 74.3% predictive ability and no difference between predicted and observed values.

INTERPRETATION

This study provides a risk calculator to identify the risk of SSI after spine surgery for patients with CP. This will allow us to enhance decision-making and patient care while providing valid hospital comparisons, public reporting mechanisms, and reimbursement determinations.

Spinal Deformity Surgery in Pediatric Patients With Cerebral Palsy: A National-Level Analysis of Inpatient and Postdischarge Outcomes

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To provide a national-level assessment of the short-term outcomes after spinal deformity surgery in pediatric patients with cerebral palsy.

METHODS

A national, prospectively collected database was queried to identify pediatric (≤18 years) patients with cerebral palsy, who underwent spinal fusion surgery from 2012 to 2017. Separate multivariate analyses were performed for the primary outcomes of interest including extended length of stay (>75th percentile, >8 days), and readmissions within 90 days after the index admission.

RESULTS

A total of 2856 patients were reviewed. The mean age ± standard deviation was 12.8 ± 2.9 years, and 49.4% of patients were female. The majority of patients underwent a posterior spinal fusion (97.0%) involving ≥8 levels (79.9%) at a teaching hospital (96.6%). Top medical complications (24.5%) included acute respiratory failure requiring mechanical ventilation (11.4%), paralytic ileus (8.2%), and urinary tract infections (4.6%). Top surgical complications (40.7%) included blood transfusion (35.6%), wound complication (4.9%), and mechanical complication (2.7%). The hospital cost for patients with a length of hospital stay >8 days ($113 669) was nearly double than that of those with a shorter length of stay ($68 411). The 90-day readmission rate was 17.6% (mean days to readmission: 30.2). The most common reason for readmission included wound dehiscence (21.1%), surgical site infection (19.1%), other infection (18.9%), dehydration (16.9%), feeding issues (14.5%), and acute respiratory failure (13.1%). Notable independent predictors for 90-day readmissions included preexisting pulmonary disease (odds ratio [OR] 1.5), obesity (OR 3.4), cachexia (OR 27), nonteaching hospital (OR 3.5), inpatient return to operating room (OR 1.9), and length of stay >8 days (OR 1.5).

CONCLUSIONS

Efforts focused on optimizing the perioperative pulmonary, hematological, and nutritional status as well as reducing wound complications appear to be the most important for improving clinical outcomes.

A national analysis on complications and readmissions for adult cerebral palsy patients undergoing primary spinal fusion surgery

STUDY DESIGN

Retrospective National Database Study.

OBJECTIVE

Surgical intervention with spinal fusion is often indicated in cerebral palsy (CP) patients with progressive scoliosis. The purpose of this study was to utilize the National Readmission Database to determine the national estimates of complication rates, 90-day readmission rates, and costs associated with spinal fusion in adult patients with CP.

METHODS

The 2012-2015 NRD databases were queried for all adult (age ≥ 19 years) patients diagnosed with CP (ICD-9: 333.71, 343.0-4, and 343.8-9) undergoing spinal fusion (ICD-9: 81.00-08).

RESULTS

1166 adult patients with CP (42.7% female) underwent spinal fusion surgery between 2012 and 2015. 153 (13.1%) were readmitted within 90 days following the primary surgery, with a mean 33.8 ± 26.5 days. Mean hospital charge of the primary admission was $141,416 ± $157,359 and $167,081 ± $145,416 for the non-readmitted and readmitted patients, respectively (p = 0.06). The mean 90-day readmission charge was $72,479 ± $104,100. Most common complications with the primary admission included UTIs (no readmission vs. readmission: 7.6% vs. 4.8%; p = 0.18), respiratory (6.9% vs. 5.6%; p = 0.62), implant (3.8% vs. 6.0%; p = 0.21), and paralytic ileus (3.6% vs. 3.2%; p = 0.858). Multivariate analyses demonstrated the following as independent predictors for 90-day readmission: comorbid anemia (OR: 2.8; 95% CI: 1.6-4.9; p < 0.001), coagulopathy (2.9, 1.1-8.0, 0.037), perioperative blood transfusion (2.0, 1.1-3.8, 0.026), wound complication (6.4, 1.3-31.6, 0.023), and transfer to short-term hospital versus routine disposition (4.9, 1.0-23.3, 0.045).

CONCLUSION

Quality improvement efforts should be aimed at reducing rates of infection related complications as this was the most common reason for short-term complications and unplanned readmission following surgery.

Effect of narcotic prescription limiting legislation on opioid utilization following pediatric spinal fusion for scoliosis

BACKGROUND CONTEXT

Since 2016, 35 of 50 US states have approved opioid-limiting and monitoring laws. The impact on postoperative opioid prescribing and secondary outcomes following pediatric scoliosis deformity correction surgery remains unknown.

PURPOSE

To evaluate the effect of CURES 2.0 opioid-limiting regulations on postoperative opioid prescriptions and unplanned readmissions following pediatric scoliosis deformity correction surgery.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

Two patient cohorts (pre-CURES January 1, 2017-October 22, 2018 and post-CURES September 1, 2018-May 30, 2020) that included all patients undergoing pediatric scoliosis deformity surgery at a single institution.

METHODS

Demographic, medical, surgical, clinical, and pharmacological data was collected from all patients. Total morphine milligram equivalents (MMEs) prescribed was compared at 30-day postoperative intervals. Readmission rates were calculated. Categorical variables were evaluated with Chi squared analysis and continuous variables were evaluated with t test or Mann-Whitney U test as appropriate. Logistic regression was used to evaluate risk factors for increased postoperative opioid.

RESULTS

Of 108 identified patients, 94 (49 pre-CURES, 45 post-CURES) were included in the study. Post-CURES patients were older (p = 0.001). All other demographic, medical, and surgical factors were similar between pre-CURES and post-CURES patients (all p > 0.05). Post-CURES, patients received fewer pills in their first postoperative prescription (43.4 vs. 57.4 pills, p = 0.006), less opioids (MMEs) during the first 0 to 30-day and 31 to 60-day postoperative intervals (261.8 MMEs vs. 337.6 MMEs, p = 0.028 and 17.8 MMEs vs. 59.7 MMEs, p = 0.016, respectively). Increased 120-day opioid utilization was associated with surgery in the pre-CURES period, age, BMI, and decreased number of levels fused (all p < 0.05). Postoperative readmission within 90 days was associated with age, BMI, number of levels fused, and length of stay.

CONCLUSIONS

Implementation of CURES 2.0 has resulted in a reduction in the opioid prescription following pediatric scoliosis deformity surgery without an increase in readmissions. Further studies are needed to evaluate how legislations of this kind affect patient reported outcomes, satisfaction, and quality of life.

A Clinical Risk Model for Surgical Site Infection Following Pediatric Spine Deformity Surgery

BACKGROUND

Despite tremendous efforts, the incidence of surgical site infection (SSI) following the surgical treatment of pediatric spinal deformity remains a concern. Although previous studies have reported some risk factors for SSI, these studies have been limited by not being able to investigate multiple risk factors at the same time. The aim of the present study was to evaluate a wide range of preoperative and intraoperative factors in predicting SSI and to develop and validate a prediction model that quantifies the risk of SSI for individual pediatric spinal deformity patients.

METHODS

Pediatric patients with spinal deformity who underwent primary, revision, or definitive spinal fusion at 1 of 7 institutions were included. Candidate predictors were known preoperatively and were not modifiable in most cases; these included 31 patient, 12 surgical, and 4 hospital factors. The Centers for Disease Control and Prevention definition of SSI within 90 days of surgery was utilized. Following multiple imputation and multicollinearity testing, predictor selection was conducted with use of logistic regression to develop multiple models. The data set was randomly split into training and testing sets, and fivefold cross-validation was performed to compare discrimination, calibration, and overfitting of each model and to determine the final model. A risk probability calculator and a mobile device application were developed from the model in order to calculate the probability of SSI in individual patients.

RESULTS

A total of 3,092 spinal deformity surgeries were included, in which there were 132 cases of SSI (4.3%). The final model achieved adequate discrimination (area under the receiver operating characteristic curve: 0.76), as well as calibration and no overfitting. Predictors included in the model were nonambulatory status, neuromuscular etiology, pelvic instrumentation, procedure time ≥7 hours, American Society of Anesthesiologists grade >2, revision procedure, hospital spine surgical cases <100/year, abnormal hemoglobin level, and overweight or obese body mass index.

CONCLUSIONS

The risk probability calculator encompassing patient, surgical, and hospital factors developed in the present study predicts the probability of 90-day SSI in pediatric spinal deformity surgery. This validated calculator can be utilized to improve informed consent and shared decision-making and may allow the deployment of additional resources and strategies selectively in high-risk patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Readmissions after ventricular shunting in pediatric patients with hydrocephalus: a Nationwide Readmissions Database analysis

OBJECTIVE

Cerebrospinal fluid diversion via ventricular shunting is a common surgical treatment for hydrocephalus in the pediatric population. No longitudinal follow-up data for a multistate population-based cohort of pediatric patients undergoing ventricular shunting in the United States have been published. In the current review of a nationwide population-based data set, the authors aimed to assess rates of shunt failure and hospital readmission in pediatric patients undergoing new ventricular shunt placement. They also review patient- and hospital-level factors associated with shunt failure and readmission.

METHODS

Included in this study was a population-based sample of pediatric patients with hydrocephalus who, in 2010-2014, had undergone new ventricular shunt placement and had sufficient follow-up, as recorded in the Nationwide Readmissions Database. The authors analyzed the rate of revision within 6 months, readmission rates at 30 and 90 days, and potential factors associated with shunt failure including patient- and hospital-level variables and type of hydrocephalus.

RESULTS

A total of 3520 pediatric patients had undergone initial ventriculoperitoneal shunt placement for hydrocephalus at an index admission. Twenty percent of these patients underwent shunt revision within 6 months. The median time to revision was 44.5 days. Eighteen percent of the patients were readmitted within 30 days and 31% were readmitted within 90 days. Different-hospital readmissions were rare, occurring in ≤ 6% of readmissions. Increased hospital volume was not protective against readmission or shunt revision. Patients with grade 3 or 4 intraventricular hemorrhage were more likely to have shunt malfunctions. Patients who had private insurance and who were treated at a large hospital were less likely to be readmitted.

CONCLUSIONS

In a nationwide, population-based database with longitudinal follow-up, shunt failure and readmission were common. Although patient and hospital factors were associated with readmission and shunt failure, system-wide phenomena such as insufficient centralization of care and fragmentation of care were not observed. Efforts to reduce readmissions in pediatric patients undergoing ventricular shunt procedures should focus on coordinating care in patients with complex neurological diseases and on reducing healthcare disparities associated with readmission.

Postoperative Management Strategy of Surgical Site Infection following Lumbar Dynesys Dynamic Internal Fixation

Aim

To research the incidence of surgical site infection (SSI) following lumbar Dynesys dynamic internal fixation and its management strategy.

Methods

We retrospectively analyzed all cases of lumbar Dynesys dynamic internal fixation performed from January 2010 to December 2019, and the data from patients with SSI were collected. The observational indicators included the incidence of SSI, general information of the patients, surgical details, inflammatory indicators, pathogenic bacteria, and treatment. SSI was defined as both early infection and delayed infection, and the cases were divided into Groups A and B, respectively. The relevant indicators and treatment were compared between the two groups.

Results

A total of 1125 cases of lumbar Dynesys dynamic internal fixation were followed up. Twenty-five cases of SSI occurred, and the incidence of SSI was 2.22% (25/1125). There were 14 cases of early infection (1.24%) and 11 cases of delayed infection (0.98%). Fourteen cases of early infection occurred 12.3 ± 8.3 days postoperatively (3–30), and 11 cases of delayed infection occurred 33.3 ± 18.9 months postoperatively (3–62). The inflammatory indicators of Group A were significantly higher than those of Group B (all P < 0.05), except for procalcitonin. The main infection site in Group A was located on the skin and subcutaneous tissue and around the internal instrument, while the main infection site in Group B was around the internal instrument. The main treatment for Group A was debridement and implant replacement, and the main treatment for Group B was implant removal. Summary. The incidence of SSI following lumbar Dynesys dynamic internal fixation was 2.22%, the incidence of early SSI was 1.24%, and the incidence of delayed SSI was 0.98%. If the main infection site of early infection is in the incision, debridement should be the main treatment method; if the infection site is around the internal fixation, implant replacement is recommended on the basis of debridement. Once delayed infection is diagnosed, implant removal is suggested.

Complications in ambulatory pediatric patients with nonidiopathic spinal deformity undergoing fusion to the pelvis using the sacral-alar-iliac technique within 2 years of surgery

OBJECTIVE

Significant investigation in the adult population has generated a body of research regarding proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following long fusions to the sacrum and pelvis. However, much less is known regarding early complications, including PJK and PJF, in the ambulatory pediatric patient. As such, the objective of this study was to address the minimal literature on early complications after ambulatory pediatric patients underwent fusion to the sacrum with instrumentation to the pelvis in the era of sacral-alar-iliac (S2AI) instrumentation.

METHODS

The authors performed a retrospective review of pediatric patients with nonidiopathic spinal deformity < 18 years of age with ambulatory capacity who underwent fusion to the pelvis at a multisurgeon pediatric academic spine practice from 2016 to 2018. All surgeries were posterior-only approaches with S2AI screws as the primary technique for sacropelvic fixation. Descriptive, outcome, and radiographic data were obtained. The definition of PJF included symptomatic PJK presenting as fracture, screw pullout, or disruption of the posterior osseoligamentous complex.

RESULTS

Twenty-five patients were included in this study. Nine patients (36.0%) had 15 complications for an overall complication rate of 60.0%. Unplanned return to the operating room occurred 8 times in 6 patients (24.0%). Four patients (16.0%) had wound issues (3 with deep wound infection and 1 with wound breakdown) requiring reoperation. Three patients (12.0%) had PJF, all requiring reoperation. A 16-year-old female patient with syndromic scoliosis underwent extension of fusion due to posterior tension band failure at 6 months. A 17-year-old male patient with neuromuscular scoliosis underwent extension of fusion due to proximal screw pullout at 5 months. A 10-year-old female patient with congenital scoliosis underwent extension for PJF at 5 months following posterior tension band failure. One patient had pseudarthrosis requiring reoperation 20 months postoperatively.

CONCLUSIONS

Fixation to the pelvis enables significant deformity correction, but with rather high rates of complications and unexpected returns to the operating room. Considerations of sagittal plane dynamics for PJK and PJF should be strongly analyzed when performing fixation to the pelvis in ambulatory pediatric patients.

Early and late hospital readmissions in adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective review of a prospectively collected multicenter database.

OBJECTIVES

To identify risk factors for early and late readmission of surgically treated patients with adolescent idiopathic scoliosis (AIS). Specific risk factors associated with readmission in patients with AIS remain poorly understood.

METHODS

Patients with AIS who were operatively treated from 19 centers specializing in the treatment of pediatric spinal deformity were studied. Data from a minimum 2 years of clinical follow-up and any readmission were available for analysis. Characteristics of patients with no readmission, early readmission (< 90 days), and late readmission (> 90 days) were evaluated. Both univariate and multivariate analyses of risk factors for readmission were performed.

RESULTS

2049 patients were included in our cohort, with 1.6% requiring early readmission and 3.3% late readmission. In the multivariate analysis, greater preoperative coronal imbalance was associated with early readmission. Longer operative time was associated with late readmission. Finally, greater preoperative pain (SRS-22 pain scale) was associated with both early and late readmission. GI complications accounted for a higher proportion of early readmissions than previously reported in the literature.

CONCLUSIONS

Preoperative counseling of patients with higher levels of pain and coronal imbalance and the implementation of a thorough postoperative bowel regimen may help optimize patient outcomes.

LEVEL OF EVIDENCE

3.

Development of a Shared Decision-Making Tool for Adolescents With Scoliosis to Decide Between Observation Versus Fusion Surgery

BACKGROUND

Adolescent patients with moderate to severe idiopathic scoliosis who have completed their skeletal growth face a significant choice in their treatment path: watchful waiting or spinal fusion. Shared decision making (SDM) assists patients and clinicians to find treatments that make intellectual, practical and emotional sense. Our objective was to develop a tool that supports SDM for patients with scoliosis and their families.

METHODS

We used a user-centered design approach that included collaboration between patients, surgeons and SDM experts, observation of clinician encounters, and literature review. We focused on adolescent idiopathic scoliosis patients 13 or more years of age with less than 1 year of growth remaining (Risser stage 3 or greater) and curves between 40 and 65 degrees.

RESULTS

We included 22 patients, and collected 22 video recordings. From these videos, we identified salient patient priorities for decision making including treatment benefits, surgical complications, pain, scheduling and recovery, and cost. For each theme, we conducted a focused review to obtain the best estimate of effect. Then, an expert SDM designer developed an electronic prototype called Scoliosis Choice.

CONCLUSIONS

The initial prototype of the scoliosis SDM was finalized and is currently being field tested in clinic. Scoliosis Choice may help patients and surgeons better understand the potential risks and benefits of spinal fusion vs. observation for scoliosis treatment and improve validated measures of quality in patient-parent-surgeon communication.

Incidence and Risk Factors for Unplanned Return to the Operating Room Following Primary Definitive Fusion for Pediatric Spinal Deformity: A Multicenter Study with Minimum 2-year Follow-Up

STUDY DESIGN

A retrospective multicenter cohort study.

OBJECTIVE

The aim of this study was to identify the incidence and risk factors for UPROR within minimum 2-year follow-up in primary definitive fusion for pediatric spinal deformity.

SUMMARY OF BACKGROUND DATA

Several previous reports have elucidated the incidence of complications after pediatric scoliosis surgery; however, there has been no study that described the incidence and risk factors for unplanned return to the operating room (UPROR) with long-term follow-up in surgery for pediatric scoliosis with every etiology.

METHODS

We retrospectively extracted data of patients aged <19 years, from 14 institutes in Japan, who underwent primary definitive fusion surgery for spinal deformity between January 1, 2015 and December 31, 2017. The primary outcomes were the incidence of UPROR within the minimum 2-year follow-up period for any reason. Univariate and multivariate logistical analyses were conducted to identify potential risk factors associated with UPROR.

RESULTS

We identified 1417 eligible patients (287 males and 1130 females) with a mean age of 13.9 years. UPROR for any reason within minimum 2-year follow-up was identified in 68 patients (4.8%). The most frequent cause for UPROR was implant failure found in 29 patients, followed by surgical site infection in 14 patients, junctional problems in 10 patients, and neurological complications in six patients. The multivariate logistic regression analysis revealed that a diagnosis of kyphosis (odds ratio [OR], 2.65; 95% confidence interval [CI] 1.16-6.04), etiology of congenital or structural type (OR 2.21; 95% CI 1.08-4.53), etiology of syndromic type (OR 2.67; 95% CI 1.27-5.64), and increased operation time of ≥300 minutes (OR 1.81; 95% CI 1.07-3.07) were the risk factors for the incidence of UPROR.

CONCLUSION

The present multicenter study identified for the first time the incidence and risk factors for UPROR with minimum 2-year follow-up after primary definitive fusion surgery for pediatric spinal deformity with every etiology.Level of Evidence: 3.

Length of stay, readmission, and mortality after primary surgery for pediatric spinal deformities: a 10-year nationwide cohort study

BACKGROUND CONTEXT

Extended length of stay (extLOS) and unplanned readmissions after first time pediatric spinal deformity surgery are a considerable challenge to both the patient and the health-care system. To our knowledge, only a limited number of nationwide studies reporting short-term comorbidity with complete follow-up exist.

PURPOSE

The purpose of this study was to identify the postoperative complications leading to extLOS, readmissions, and mortality within 90 days after surgery. Furthermore, to identify risk factors for readmission.

DESIGN

Retrospective national cohort study.

PATIENT SAMPLE

A nationwide registry study including all pediatric spinal deformity patients (≤21 years of age) undergoing primary surgery during 2006-2015 (n=1,310).

OUTCOME MEASURES

Reasons for extLOS and 90-day readmissions as well as mortality risk.

METHODS

Patients were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Data on length of stay (LOS), readmissions, and mortality within 90 days were retrieved from the DNPR. Patients were categorized in six groups according to etiology. Reasons for extLOS and readmission were collected from medical records and discharge summaries.

RESULTS

For the 1,310 patients, the median LOS was 8 days (interquartile range 7-9). Etiologies were idiopathic deformity (53%), neuromuscular deformity (23%), congenital/structural deformity (9%), spondylolisthesis (7%), Scheuermann kyphosis (5%), and syndromic deformity (3%). A total of 274 (21%) patients had extLOS and the most common reason was pain/mobilization issues but with considerable variation between etiologies; Scheuermann kyphosis (91%), idiopathic (59%), syndromic (44%), spondylolisthesis (38%), and congenital (30%). Pulmonary complications were the primary reason for extLOS in the neuromuscular group (22%). The 90-day readmission rate was 6%; 67% of readmissions were medical, mainly infections unrelated to the surgical site (23%); 33% of readmissions were surgical and 14% of patients required revision surgery. Neuromuscular deformity, spondylolisthesis, Scheuermann kyphosis, and LOS >9 days were independent risk factors for readmission; odds ratio (OR) 4.4 (95% confidence interval: 2.2-9.1, p<.01), OR 3.0 (1.1-8.0, p=.03), OR 4.9 (1.7-13.6, p<.01), and OR 1.8 (1.0-3.1, p=.04), respectively. The 90-day mortality risk was 0.4%.

CONCLUSIONS

In this nationwide cohort, pain/mobilization issues are the most common reason for extLOS. The most common reason for readmission is infection unrelated to the surgical site. Readmission after pediatric spinal surgery is related to the etiology and increased focus on patients operated for neuromuscular deformity, spondylolisthesis and Scheuermann kyphosis is warranted.

Revision risk after pediatric spinal deformity surgery: a nationwide study with 2-year follow-up

BACKGROUND CONTEXT

Revision risk after pediatric spine surgery is not well established and varies between deformity etiologies.

PURPOSE

To report the 2-year revision risk following surgery for primary pediatric spinal deformity in a nationwide cohort and to evaluate potential risk factors and reasons for revision surgery.

DESIGN

Retrospective nationwide cohort study.

PATIENT SAMPLE

A national registry study of all pediatric spinal deformity patients undergoing surgery during 2006-2015 (n=1310).

OUTCOME MEASURES

Two-year revision risk.

METHODS

All patients ≤21 years of age undergoing spinal deformity surgery in Denmark during 2006-2015 were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Data on revision surgery were retrieved from the DNPR. Patients were categorized in six groups according to etiology. Medical records were reviewed for reason for revision in all patients. Potential risk factors for revision were assessed with multiple logistic regression analyses and included age, etiology, sex, Charlson comorbidity index (CCI), and growth-preserving treatment.

RESULTS

Patients were categorized according to etiology: idiopathic deformity (53%), neuromuscular deformity (23%), congenital/structural deformity (9%), spondylolisthesis (7%), Scheuermann's kyphosis (5%), and syndromic deformity (3%). Of 1,310 included patients, 9.2% underwent revision surgery within 2 years and 1.5% was revised more than once. Median time to revision was 203 (interquartile range 35-485) days. The multivariable logistic regression found significantly higher odds ratio (OR) for revision in patients with growth-preserving treatment (OR=5.1, 95% confidence interval [CI] 2.6-10.1), congenital deformity (OR=2.7, 95% CI 1.3-5.3), spondylolisthesis (OR=3.5, 95% CI 1.9-6.7), Scheuermann kyphosis (OR=3.9, 95% CI 1.9-8.3), and CCI score ≥3 (OR=2.5 95% CI 1.1-5.6). The most common reason for revision was implant failure (32.5%) followed by residual deformity and/or curve progression (15.8%).

CONCLUSIONS

In this nationwide study, the 2-year revision risk after primary pediatric spinal deformity surgery is 9.2%. Risk factors for revision are etiology of congenital deformity, spondylolisthesis, Scheuermann kyphosis as well as patients with growth-preserving treatment and higher CCI. The most common reason for revision is implant failure.

Factors Affecting Length of Stay Following 3-Column Spinal Osteotomies in Pediatric Patients

STUDY DESIGN

A retrospective analysis.

OBJECTIVES

Length of stay (LOS) is one of the important indicators for the quality of patient care. Although perioperative complications are known to be associated with longer LOS in general, little has been understood regarding LOS after 3-column spinal osteotomy for the rigid spinal deformity in pediatric population. The main objective of the article is to identify factors affecting the LOS in pediatric patients undergoing 3-column posterior spinal osteotomies.

METHODS

Following research ethics approval, a retrospective review was performed of 35 consecutive posterior 3-column spinal osteotomies performed on pediatric patients in a single academic institution. Patients' demographic data, preoperative comorbidities, details of operative procedures, intraoperative complications, and postoperative complications were investigated, and LOS was compared among the groups.

RESULTS

The mean LOS was 9.0 days, and the median LOS was 7 days (range = 4-23 days). Low body weight and syndromic deformity were associated with longer LOS. Operation time ≥6 hours and total perioperative fluid administration greater than or equal to twice the estimated blood volume were associated with longer LOS. Among postoperative complications, those with respiratory complication had prolonged stay.

CONCLUSIONS

Preoperative low body weight and syndromic scoliosis had longer LOS after 3-column osteotomies. Excessive fluid administration and respiratory complications were associated with longer LOS.

The risks, reasons, and costs for 30- and 90-day readmissions after fusion surgery for adolescent idiopathic scoliosis

OBJECTIVE

With the continued evolution of bundled payment plans, there has been a greater focus within orthopedic surgery on quality metrics up to 90 days of care. Although the Centers for Medicare and Medicaid Services does not currently penalize hospitals based on their pediatric readmission rates, it is important to understand the drivers for unplanned readmission to improve the quality of care and reduce costs.

METHODS

The National Readmission Database provides a nationally representative sample of all discharges from US hospitals and allows follow-up across hospitals up to 1 calendar year. Adolescents (age 10-18 years) who underwent idiopathic scoliosis surgery from 2012 to 2015 were included. Patients were separated into those with and those without readmission within 30 days or between 31 and 90 days. Demographics, operative conditions, hospital factors, and surgical outcomes were compared using the chi-square test and t-test. Independent predictors for readmissions were identified using stepwise multivariate logistic regression.

RESULTS

A total of 30,677 patients underwent adolescent idiopathic scoliosis surgery from 2012 to 2015. The rates of 30- and 90-day readmissions were 2.9% and 1.4%, respectively. The mean costs associated with the index admission and 30- and 90-day readmissions were $60,680, $23,567, and $16,916, respectively. Common risk factors for readmissions included length of stay > 5 days, obesity, neurological disorders, and chronic use of antiplatelets or anticoagulants. The index admission complications associated with readmissions were unintended durotomy, syndrome of inappropriate antidiuretic hormone, and superior mesenteric artery syndrome. Hospital factors, discharge disposition, and operative conditions appeared to be less important for readmission risk. The top reasons for 30-day and 90-day readmissions were wound infection (34.7%) and implant complications (17.3%), respectively. Readmissions requiring a reoperation were significantly higher for those that occurred between 31 and 90 days after the index readmission.

CONCLUSIONS

Readmission rates were low for both 30- and 90-day readmissions for adolescent idiopathic scoliosis surgery patients. Nevertheless, readmissions are costly and appear to be associated with potentially modifiable risk factors, although some risk factors remain potentially unavoidable.

Parent Perspectives on Short-Term Recovery After Spinal Fusion Surgery in Children With Neuromuscular Scoliosis

Family perspectives on short-term recovery after spinal fusion for neuromuscular scoliosis are essential for improving patient outcomes. Semistructured interviews were conducted with 18 families of children within 3 months after spinal fusion performed August 2017 to January 2019 at a children's hospital. Interviews were recorded, transcribed, and coded line-by-line by 2 independent reviewers using grounded theory to identify themes. Five themes emerged among families when reflecting back on the postoperative recovery: (1) communicating and making shared decisions regarding postoperative care in a patient- and family-centered manner, (2) setting hospital discharge goals and being ready for discharge, (3) planning for transportation from hospital to home, (4) acquiring supports for caregiving at home after discharge, and (5) anticipating a long recovery at home. Important family perceptions were elicited about the recovery of children from spinal fusion for neuromuscular scoliosis that will inform better perioperative planning for clinicians, future patients, and their families.

Spinal fusion in pediatric patients with marfan syndrome: a nationwide assessment on short-term outcomes and readmission risk

PURPOSE

The purpose of this study was to utilize the National Readmission Database (NRD) to determine estimates for complication rates, 90-day readmission rates, and hospital costs associated with spinal fusion in pediatric patients with Marfan syndrome.

METHODS

The 2012-2015 NRD databases were queried for all pediatric (< 19 years old) patients diagnosed with Marfan syndrome undergoing spinal fusion surgery. The primary outcome variables in this study were index admission complications and 90-day readmissions.

RESULTS

A total of 249 patients with Marfan syndrome underwent spinal fusion surgery between 2012 and 2015 (mean age ± standard deviation at the time of surgery: 14 ± 2.0, 132 (53%) female). 25 (10.1%) were readmitted within 90 days of the index hospital discharge date. Overall, 59.7% of patients experienced at least one complication during the index admission. Unplanned 90-day readmission could be predicted by older age (odds ratio 2.3, 95% confidence interval 1.3-4.2, p = 0.006), Medicaid insurance status (56.0, 3.8-820.0, p = 0.003), and experiencing an inpatient medical complication (42.9, 4.6-398.7, p = 0.001). Patients were readmitted for wound dehiscence (8 patients, 3.2%), nervous system related complications (3 patients, 1.2%), and postoperative infectious related complications (4 patients, 1.6%).

CONCLUSION

This study is the first to demonstrate on a national level the complications and potential risk factors for 90-day hospital readmission for patients with Marfan syndrome undergoing spinal fusion. Patients with Marfan syndrome undergoing spinal fusion often present with multiple medical comorbidities that must be managed carefully perioperatively to reduce inpatient complications and early hospital readmissions.

Emergency Department Visits After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

BACKGROUND

The incidence of emergency department (ED) visits after posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS) patients is not well known. We hypothesize that the majority of ED visits are related to constipation and pain issues, and are not for serious complications.

METHODS

Using a private insurance claims database, we identified AIS patients aged 10 to 21 years who underwent PSF from 2010 to 2015. Patients were excluded for diagnoses of neuromuscular or syndromic scoliosis. ED visits that occurred within the 6-month postoperative period were identified. The diagnoses present at these visits were pooled and analyzed, in addition to insurance payments associated with these visits. Significance was set at P=0.05.

RESULTS

A total of 5934 patients met inclusion criteria. Mean age was 14.4±2.2 years, and 75% of the patients were girls. A total of 577 (9.7%) patients had at least 1 ED visit in the 6-month postoperative period, whereas 92 (1.6%) had 2 ED visits and 19 (0.3%) had 3 or more ED visits. The median time to ED visits was 33 days after surgery. Independent risk factors for ED visits were: older age, and greater levels fused (P<0.05). The top 5 most common reasons for ED visits were: pain/back or musculoskeletal, constipation/GI issues, asthma/ respiratory issues, upper respiratory infection, and dehydration. Rates of ED visits were similar among the US geographic regions. Patients who had an ED visit had significantly higher total 6-month health care payments than those who did not (P<0.001).

CONCLUSIONS

Approximately 10% of the patients had ≥1 ED visit in the 6-month period after PSF for AIS. A majority of the diagnoses at these ED visits were outpatient medical issues.

LEVEL OF EVIDENCE

Level III.

Early and late hospital readmissions after spine deformity surgery in children with cerebral palsy

STUDY DESIGN

Retrospective review of a prospectively collected multicenter registry of pediatric patients with cerebral palsy (CP) and neuromuscular scoliosis (NMS) undergoing spinal fusion.

OBJECTIVE

To define risk factors for unplanned readmission after elective spinal deformity surgery. Patients with CP and NMS have high rates of hospital readmission; however, risk factors for readmission are not well established.

METHODS

Univariate and multivariate analyses were used to compare the demographics, operative and postoperative course, radiographic characteristics, and preoperative Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaires of patients who did not require readmission to those who required either early readmission (within 90 days of the index surgery) or late readmission (readmission after 90 days).

RESULTS

Of the 218 patients identified, 19 (8.7%) required early readmission, while 16 (7.3%) required late readmission. Baseline characteristics were similar between the three cohorts. On univariate analysis, early readmission was associated with longer duration of surgery (p < 0.001) and larger magnitude of residual deformity (p = 0.003 and p = 0.029 for postoperative major and minor angles, respectively). The health score of the CPCHILD Questionnaire was lower in patients who required early readmission than in those who did not require readmission (p = 0.032). On multivariate analysis, oral feeding status was inversely related to early readmission (less likely to require readmission), while decreasing lumbar lordosis and increasing length of surgery were related to an increased likelihood of early readmission.

CONCLUSIONS

In patients with CP and NMS, longer surgical time, larger residual major and minor Cobb angles, lumbar lordosis, feeding status, and overall health may be related to a greater likelihood for early hospital readmission after elective spinal fusion. No factors were identified that correlated with an increased need for late hospital readmission after elective spinal fusion in patients with CP.

LEVEL OF EVIDENCE

IV.

Readmission following complex spine surgery in a prospective cohort of 679 patients - 2-years follow-up using the Spine AdVerse Event Severity (SAVES) system

BACKGROUND CONTEXT

Recent studies suggest that prospective registration more accurately reflects the true incidence of adverse events (AEs). To our knowledge, no previous study has investigated prospectively registered AEs' influence on hospital readmission following spine surgery.

PURPOSE

To determine the frequency and type of unplanned readmissions after complex spine surgery, and to investigate if prospectively registered AEs can predict readmissions.

DESIGN

This is a prospective, consecutive cohort study.

PATIENT SAMPLE

We conducted a single-center study of 679 consecutive patients who underwent complex spine surgery defined as conditions deemed too complicated for surgery at a secondary institute, or patients with severe comorbidities requiring multidisciplinary observation and treatment.

OUTCOME MEASURES

The outcomes in this study were (1) readmission to any hospital department within 30 days of discharge and (2) readmission to a surgical spine center at any time in follow-up.

METHODS

All patients undergoing complex spine surgery, at our tertiary referral center, were consecutively, and prospectively, included from January 1 to December 31, 2013. Demographics and perioperative AEs were registered using the Spine AdVerse Events Severity (SAVES) system. Patients were followed for a minimum of two years. A competing risk survival model was used to estimate rates of readmissions with death as a competing risk. Patient characteristics, surgical parameters and perioperative AEs were analyzed to identify factors associated with readmission. Analyses of 30-day readmission were performed using logistic regression models. A proportional odds model, with death as competing risk, was used for readmissions to a spine center at any time in follow-up. Results were reported as odds ratios with 95% confidence intervals (95% CI).

RESULTS

Within 2 years of index discharge, 443 (65%) were readmitted. Only 20% of readmissions were to a spine center. Cumulative incidence (95% CI) of readmission was estimated to 13% (10%-16%) at 30 days, 26% (23%-30%) at 90 days, 50% (46%-54%) at 1 year, and 59% (55%-63%) at 2 years following discharge. Rates were markedly lower for readmissions to a spine center. Increased odds of 30-day readmission were correlated to intraoperative hypotension (p=.02) and major intraoperative blood loss (p<.01). Readmission to a spine center was associated with the number of instrumented vertebrae (p=.047), major intraoperative AE (p=.01), and intraoperative hypotension (p<.01).

CONCLUSIONS

To the best of our knowledge, this is the first study to analyze prospectively registered AEs' association to readmission up to 2 years after complex spine surgery. We found that readmissions were more frequent than previously reported when including readmissions to any department or hospital. Factors related to major intraoperative blood loss were associated to increased odds of readmission. This should be considered during planning of postoperative observation and care.

Timing of Complications After Posterior Spinal Fusions in Pediatric Spine Deformity

STUDY DESIGN

Retrospective cross-sectional survey.

OBJECTIVE

To investigate the timing of complications after posterior spinal fusion for idiopathic and neuromuscular pediatric spine deformity.

SUMMARY OF BACKGROUND DATA

Evidence is limited with regard to when complications occur after posterior spinal fusions in pediatric spine deformities.

METHODS

The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database files were queried using Current Procedural Terminology codes (22800, 22802, and 22804) for patients undergoing posterior spinal fusion for idiopathic or neuromuscular deformity. Median day-of-diagnosis and interquartile ranges were calculated for database-recorded complications.

RESULTS

A total of 10,579 patients were included in the study. The frequency and median day of diagnosis of each complication are as follows: superficial surgical site infection (SSI) (idiopathic = 0.6%, Day 18.5; neuromuscular = 1.6%, Day 19.5), deep SSI (idiopathic = 0.5%, Day 16.0; neuromuscular = 2.3%, Day 18), organ/space SSI (idiopathic = 0.1%, Day 17; neuromuscular = 0.4%, Day 16), wound disruption (idiopathic = 0.4%, Day 15; neuromuscular = 1.2%, Day 15), pneumonia (idiopathic = 0.6%, Day 5; neuromuscular = 4.0%, Day 3), unplanned intubation (idiopathic = 0.4%, Day 2; neuromuscular = 3.5%, Day 1), urinary tract infection (idiopathic = 0.4%, Day 6; neuromuscular = 2.8%, Day 4.5), nerve injury causing neurologic deficit (idiopathic = 0.4%, Day 1; neuromuscular = 0.3%, Day 5), bleeding requiring transfusions (idiopathic = 64.6%, Day 0; neuromuscular = 74.1%, Day 0), sepsis (idiopathic = 0.3%, Day 11; neuromuscular = 2.4%, Day 12.5), and mortality (idiopathic = ∼0%, Day 5; neuromuscular = 0.4%, Day 9).

CONCLUSION

Understanding the timing of complications is important for patients and providers, as it reflects the need of heightened awareness and low thresholds of testing during periods of highest risks to catch complications, launch appropriate optimization protocols, and minimize the cost burden associated with readmissions.

LEVEL OF EVIDENCE

Level IV.

Prediction of 30-day pediatric unplanned hospitalizations using the Johns Hopkins Adjusted Clinical Groups risk adjustment system

Background

The Johns Hopkins ACG System is widely used to predict patient healthcare service use and costs. Most applications have focused on adult populations. In this study, we evaluated the use of the ACG software to predict pediatric unplanned hospital admission in a given month, based on the past year’s clinical information captured by electronic health records (EHRs).

Methods and findings

EHR data from a multi-state pediatric integrated delivery system were obtained for 920,051 patients with at least one physician visit during January 2009 to December 2016. Over this interval an average of 0.36% of patients each month had an unplanned hospitalization. In a 70% training sample, we used the generalized linear mixed model (GLMM) to generate regression coefficients for demographic, clinical predictors derived from the ACG system, and prior year hospitalizations. Applying these coefficients to a 30% test sample to generate risk scores, we found that the area under the receiver operator characteristic curve (AUC) was 0.82. Omitting prior hospitalizations decreased the AUC from 0.82 to 0.80, and increased under-estimation of hospitalizations at the greater risk levels. Patients in the top 5% of risk scores accounted for 43% and the top 1% of risk scores accounted for 20% of all unplanned hospitalizations.

Conclusions

A predictive model based on 12-months of demographic and clinical data using the ACG system has excellent predictive performance for 30-day pediatric unplanned hospitalization. This model may be useful in population health and care management applications targeting patients likely to be hospitalized. External validation at other institutions should be done to confirm our results.

Risk Factors for Early Infection in Pediatric Spinal Deformity Surgery: A Multivariate Analysis

STUDY DESIGN

Retrospective case-control study.

OBJECTIVES

To identify risk factors for early deep surgical site infections (SSIs; within three months of index procedure) following pediatric spinal deformity surgery.

BACKGROUND

Deep surgical site infections (SSIs) following pediatric spinal deformity surgery are a source of significant morbidity. We sought to identify independent risk factors for early infection following primary, definitive single-stage pediatric posterior spinal fusion and instrumentation (PSFI).

METHODS

A total of 616 consecutive patients (2001-2016) from an institutional prospectively maintained Pediatric Orthopaedic Spine database were identified that met inclusion criteria of definitive single-stage PSFI. Early deep SSI was defined as infection within three months of index procedure requiring surgical intervention. A multivariate analysis of demographics, comorbidities, and perioperative factors was performed and independent risk factors were identified.

RESULTS

Eleven patients (1.6%) developed an early deep SSI. Independent risk factors for SSI identified were nonidiopathic (neuromuscular, syndromic, and congenital) etiologies of scoliosis (adjusted odds ratio [aOR]: 8.384, 95% confidence interval [CI]: 1.784-39.386, p = .007) and amount of intraoperative crystalloids (aOR: 1.547 per additional liter of fluid, 95% CI: 1.057-2.263, p = .025). Mean crystalloid administered in the SSI group was 3.3 ± 1.2 L versus 2.4 ± 1.0 L in the noninfected group (p = .019). On univariate analysis, there was no significant difference in weight of patients between cohorts (p = .869) or surgery time (p = .089). There was also no significant difference in infection rates from redosing of antibiotics intraoperatively after 3 hours of surgery (p = .231).

CONCLUSIONS

Nonidiopathic scoliosis and amount of intraoperative crystalloids were independently associated with early postoperative SSI. Further investigation into intraoperative fluid management may identify modifiable risk factors for early postoperative SSI in primary pediatric spinal deformity posterior spinal fusion patients.

LEVEL OF EVIDENCE

Level III, case-control study.

Gross Motor Function Classification System Specific Growth Charts-Utility as a Risk Stratification Tool for Surgical Site Infection Following Spine Surgery

BACKGROUND

There is currently minimal evidence that preoperative malnutrition increases surgical site infection (SSI) risk in children with cerebral palsy (CP) undergoing spinal deformity surgery. Growth charts specifically for patients with CP have been created to aid in the clinical interpretation of body mass index (BMI) as a marker of nutritional status, but to our knowledge these charts have never been used to risk stratify patients before orthopaedic surgery. We hypothesize that patients with CP who have BMI-for-age below the 10th percentile (BMI≤10) on CP-specific growth charts are at increased risk of surgical site infection following spinal deformity surgery compared with patients with BMI-for-age above the 10th percentile (BMI>10).

METHODS

Single-center, retrospective review comparing the rate of SSI in patients with CP stratified by BMI-for-age percentiles on CP-specific growth charts who underwent spinal deformity surgery. Odds ratios with 95% confidence intervals and Pearson χ tests were used to analyze the association of the measured nutritional indicators with SSI.

RESULTS

In total, 65 patients, who underwent 74 procedures, had complete follow-up data and were included in this analysis. Ten patients (15.4%) were GMFCS I-III and 55 (84.6%) were GMFCS IV-V; 39 (60%) were orally fed and 26 (40%) were tube-fed. The rate of SSI in this patient population was 13.5% with 10 SSIs reported within 90 days of surgery. There was a significant association between patients with a BMI below the 10th percentile on GMFCS-stratified growth charts and the development of SSI (OR, 13.6; 95% CI, 2.4-75.4; P=0.005). All SSIs occurred in patients that were GMFCS IV-V. There was no association between height, weight, feeding method, or pelvic instrumentation and development of SSI.

CONCLUSIONS

CP-specific growth charts are useful tools for identifying patients at increased risk for SSI following spinal instrumentation procedures, whereas standard CDC growth charts are much less sensitive. There is a strong association between preoperative BMI percentile on GMFCS-stratified growth charts and SSI following spinal deformity surgery.

LEVEL OF EVIDENCE

Level III-Retrospective Study.

Predictors of 90-Day Readmission in Children Undergoing Spinal Cord Tumor Surgery: A Nationwide Readmissions Database Analysis

OBJECTIVE

A fair number of hospital admissions occur after 30 days; thus, the true readmission rate could have been underestimated. Therefore, we hypothesized that the 90-day readmission rate might better characterize the factors contributing to readmission for pediatric patients undergoing spinal tumor resection.

METHODS

The Nationwide Readmissions Database was used to study the patient demographic data, comorbidities, admissions, hospital course, spinal tumor behavior (malignant vs. benign), complications, revisions, and 30- and 90-day readmissions.

RESULTS

Of the 397 patients included in the 30-day cohort, 43 (10.8%) had been readmitted. In comparison, the 90-day readmission rate was significantly greater; 52 of 325 patients were readmitted (16.0%; P < 0.04). Patients aged 16-20 constituted the largest subgroup. However, the highest readmission rate was observed for patients aged <5 years (30-day, 21.7%; 90-day, 26.4%). Medicaid patients were more likely to be readmitted than were private insurance patients (30-day odds ratio [OR], 3.3 [P < 0.001]; 90-day OR, 2.29 [P < 0.02]). In both cohorts, patients with malignant tumors required readmission more often than did those with benign tumors (30-day OR, 2.78 [P < 0.02]; 90-day OR, 1.92 [P = 0.08]). In the 90-day cohort, the patients had been readmitted 26.4 days after discharge versus 10.6 days in the 30-day cohort. Within the 90-day cohort, 18.6% of the readmissions were for spinal reoperation, 28.3% for chemotherapy or hematologic complications, and 25.6% for other central nervous system disorders. The median charges for each readmission were ∼$50,000 and ∼$40,000 for the 30- and 90-day cohorts, respectively. Medicaid insurance, malignant tumors, and younger age were significant predictors of readmission in the 90-day cohort.

CONCLUSIONS

The prevalence and charges associated with unplanned hospital readmissions after spinal tumor resection were remarkably high. Younger age, Medicaid insurance, malignant tumors, and complications during the initial admission were significant predictors of 90-day readmission.

Cost-Utility Analysis of Operative Versus Nonoperative Treatment of Thoracic Adolescent Idiopathic Scoliosis

STUDY DESIGN

Cost-utility analysis OBJECTIVE.: To compare the cost utility of operative versus nonoperative treatment of adolescent idiopathic scoliosis (AIS) and identity factors that influence cost-utility estimates.

SUMMARY OF BACKGROUND DATA

AIS affects 1% to 3% of children aged 10 to 16 years. When the major coronal curve reaches 50°, operative treatment may be considered. The cost utility of operative treatment of AIS is unknown.

METHODS

A decision-analysis model comparing operative versus nonoperative treatment was developed for a hypothetical 15-year-old skeletally mature girl with a 55° right thoracic (Lenke 1) curve. The AIS literature was reviewed to estimate the probability, health utility, and quality-adjusted life years (QALYs) for each event. For the conservative model, we assumed that operative treatment did not result directly in any QALYs gained, and the health utility in AIS patients was the same as the age-matched US population mean. Costs were inflation-adjusted at 3.22% per year to 2015 US dollars. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates.

RESULTS

Operative treatment was favored in 98.5% of simulations, with a median ICUR of $20,600/QALY (95% confidence interval, $20,500-$21,900) below the societal willingness-to-pay threshold (WTPT) of $50,000/QALY. The median incremental net monetary benefit associated with operative treatment was $15,100 (95% confidence interval, $14,800-$15,700). Operative treatment produced net monetary benefit across various WTPTs. Factors that most affected the ICUR were net costs associated with uncomplicated operative treatment, undergoing surgery during adulthood, and development of pulmonary complications.

CONCLUSION

Cost-utility analysis suggests that operative treatment of AIS is favored over nonoperative treatment and falls below the $50,000/QALY WTPT for patients with Lenke 1 curves.

LEVEL OF EVIDENCE

2.

Costs and complications of increased length of stay following adolescent idiopathic scoliosis surgery

Accelerated discharge protocols for scoliosis surgery have recently been described in the literature. There are limited data describing the association of length of stay (LOS) during the index admission with postoperative outcomes. We sought to define the economic and clinical implications of an additional 1 day in the hospital for scoliosis surgery. The Statewide Planning and Research Cooperative System database was used to identify patients with adolescent idiopathic scoliosis who underwent spinal fusion from 1 October 2007 to 30 September 2012 at high-volume institutions (>20 cases/year) in the state of New York. Regression models were adjusted for age, sex, race, insurance, comorbidity score, and perioperative complications during the index admission. Among the 1286 patients with AIS who underwent spinal fusion, the mean LOS was 4.90 days [95% confidence interval (CI)=4.84-4.97; SD=1.19]. In the perioperative period, 605 (47.05%) underwent transfusion and 202 (15.71%) had problems with pain control. An additional 1 day in the hospital was associated with $11 033 (95% CI=7162-14 904; P<0.001) in insurance charges, $5198 (95% CI=4144-6252; P<0.001) in hospital costs, 28% increased risk (odds ratio=1.28; 95% CI=1.01-1.63; P=0.041) of all-cause 90-day readmission, and a 57% increased risk (odds ratio=1.57; 95% CI=1.13-2.17; P=0.007) of returning to the operating room within 90 days. Increased LOS during the index admission scoliosis surgery is associated with higher costs and an increased risk of 90-day postoperative complications. Protocols to decrease LOS for this surgery have potential benefits to patients, hospitals, and insurers. Level of Evidence: Level III, retrospective comparative study.

Methicillin-resistant Staphylococcus aureus Swab Results Did Not Change Treatment or Outcome in Pediatric Spinal Fusion Patients

INTRODUCTION

The aim of this study was to investigate whether preoperative methicillin-resistant Staphylococcus aureus (MRSA) swab results were predictive of surgical site infections (SSIs) in pediatric patients who have undergone spinal fusion.

METHODS

We conducted a retrospective chart review of patients who underwent posterior spinal fusion between 2004 and 2014 to determine preoperative MRSA colonization status and SSI rates and organisms. Before October 1, 2012, we administered vancomycin to the patients for infection prophylaxis; beginning October 1, 2012, patients received ceftazidime and Ancef (cefazolin for injection; GlaxoSmithKline). We added powdered vancomycin to all bone grafts.

RESULTS

A total of 1,200 patients met inclusion criteria. Of the patients, 2.3% (n = 28 of 1,200) were positive for MRSA, and an SSI developed in 3.1% (n = 37 of 1,200). No significant difference in infection rates was found between patients whose MRSA swab was positive and negative (positive swab = 1 SSI, negative swab = 36 SSIs; P = 0.88). Three SSIs were caused by MRSA.

CONCLUSION

The results of a preoperative MRSA nasal swab had no correlation with SSI rates.

LEVEL OF EVIDENCE

Level III.

Does Staphylococcus aureus nasal decontamination affect the rate of early surgical site infection in adolescent idiopathic scoliosis surgery?

PURPOSE

Surgical site infection (SSI) is a main complication after adolescent idiopathic scoliosis (AIS) surgery. Nasal colonization with S. aureus is a known risk factor for developing nosocomial infections in cardiac surgery. However, the risk in orthopedic surgery remains unclear, especially in spine surgery. This study aims to report the efficacy of a preoperative nasal decontamination program in S. aureus carriers on the incidence of early SSI after AIS posterior surgery.

METHODS

Between January 2014 and July 2017, all AIS patients were screened preoperatively with nasal swabs and decontaminated if positive 5 days before surgery. Early SSI was identified, and microorganisms findings were analyzed within nasal carriage and compared to a previous series published before the decontamination program (2007-2011).

RESULTS

Among the 331 AIS posterior fusion performed during the study period, incidence of positive nasal swab was 23% (n = 75). Those were preoperatively decontaminated. In comparison with the period before the nasal decontamination program, incidence of S. aureus early SSI significantly decreased from 5.1 to 1.3%, p < 0.05. None of those S. aureus decontaminated patients had an early S. aureus SSI. In all cases of S. aureus infections, S. aureus nasal screening was negative with a mean delay of 315 days (± 115) before surgery, which was significantly different from the global cohort (104 days ± 67, p < 0.05).

CONCLUSIONS

Preoperative S. aureus nasal decontamination was associated with a significant decrease in S. aureus SSI. Optimal delay of nasal screening needs to be optimized in order to diagnose intermittent S. aureus carriers. These slides can be retrieved under Electronic Supplementary Material.

Caregiver Perceptions and Health-Related Quality-of-Life Changes in Cerebral Palsy Patients After Spinal Arthrodesis

STUDY DESIGN

A retrospective analysis of a prospective registry.

OBJECTIVE

Our objective was to prospectively assess caregivers' perceptions regarding changes in the health-related quality of life (HRQL) of patients with cerebral palsy (CP) after spinal arthrodesis. We assessed caregiver perceptions from three perspectives: 1) qualitative assessment of changes in global quality of life, comfort, and health; 2) relative valuation of spine surgery versus other common interventions in CP patients; and 3) quantitative changes in HRQL scores.

SUMMARY OF BACKGROUND DATA

Studies of children with CP who undergo surgical treatment of spinal deformity have focused largely on radiographic changes.

METHODS

We queried a multicenter prospective registry of CP patients with level IV or V motor function according to the Gross Motor Function Classification System who were treated with spinal arthrodesis, and whose caregivers completed preoperative and 2-year postoperative qualitative and quantitative HRQL surveys. A total of 212 caregivers and their patients were included in the study.

RESULTS

At 2-year follow-up, most caregivers reported that patients' global quality of life, comfort, and health were "a lot better" after spinal arthrodesis. Spinal arthrodesis was ranked as the most beneficial intervention in the patients' lives by 74% of caregivers, ahead of hip, knee, and foot surgeries and baclofen pump insertion. Gastrostomy tube insertion was the only intervention ranked superior to spinal arthrodesis in terms of impact. Quantitative HRQL scores improved significantly during 2-year follow-up across various domains.

CONCLUSION

In qualitative and quantitative HRQL assessments, caregivers reported overall improvement in patients' lives after spinal arthrodesis. Caregivers ranked spine surgery as the most beneficial intervention in the patients' lives, secondary only to gastrostomy tube insertion.

LEVEL OF EVIDENCE

2.

Impact of Readmissions in Episodic Care of Adult Spinal Deformity: Event-Based Cost Analysis of 695 Consecutive Cases

BACKGROUND

Readmissions following adult spinal deformity surgical procedures frequently occur, placing a substantial burden on patients and providers. Existing literature on readmission costs, including reason-specific readmission costs, is limited. The purposes of this study were to determine the most expensive reasons for readmission, to assess the impact of reasons and timing on readmission costs, and to estimate the drivers of total costs associated with adult spinal deformity surgical procedures.

METHODS

We performed a retrospective review of 695 patients with adult spinal deformity (≥18 years of age) who underwent a corrective spine surgical procedure at a single center from 2005 to 2013. Demographic, surgical, and direct cost data expressed in 2010 dollars for the entire inpatient episode of care were obtained from the hospital administrative database. A multivariable linear regression model with a gamma distribution and log-link function was used to estimate the impact of reasons and timing on readmission costs and to identify the primary drivers of long-term costs.

RESULTS

The mean age (and standard deviation) of the patients was 50.6 ± 15.8 years, 589 patients (85%) were women, and 637 patients (92%) were Caucasian. The observed readmission rates were 24% overall (costing $10.1 million), 8.8% for 30 days (costing $3.2 million), and 11.7% for 90 days (costing $4.6 million). The most expensive readmissions and their mean readmission cost were pseudarthrosis ($92,755), infection ($75,172), and proximal junctional kyphosis ($66,713), after adjusting for patient and surgical factors. The mean readmission cost after 2 years was $86,081. Older age (p = 0.001), ≥8 levels fused (p = 0.01), and length of index stay at the hospital (p < 0.0001) were independently associated with higher total cost. Surgical procedures in patients with a thoracic-only curve (p = 0.004) or a double curve (p = 0.05) and a surgical approach that was anterior-only (p < 0.0001) or posterior-only (p = 0.01) were independently associated with lower total costs.

CONCLUSIONS

Compared with readmission cost due to medical reasons, readmission due to pseudarthrosis increases mean readmission cost by 105%, readmission due to infection increases mean readmission cost by 72%, and readmission due to proximal junctional kyphosis increases mean readmission cost by 63%. Together, these 3 reasons accounted for 73% of readmission costs. This study identifies potential areas for cost reduction and opportunities for reducing readmission rates.

CLINICAL RELEVANCE

Although reducing the 30-day and 90-day readmission rates and costs are important; adult spinal deformity surgery is unique, because the most common and most expensive complications occur after 1 year. We believe that our paper is clinically relevant as it will help to guide clinical focus on the most impactful complications.

Unplanned readmission within 90 days after pediatric neurosurgery

OBJECTIVE Readmission and return to operating room after surgery are increasingly being used as a proxy for quality of care. Nearly 60% of these readmissions are unplanned, which translates into billions of dollars in health care costs. The authors set out to analyze the incidence of readmission at their center, to define causes of unplanned readmission, and to determine the preoperative and surgical variables associated with readmissions following pediatric neurosurgery. METHODS A total of 536 children who underwent operations for neurosurgical diagnoses between 2012 and 2015 and who were later readmitted were included in the final analysis. Unplanned readmissions were defined to have occurred as a result of complications within 90 days after index surgery. Patient records were retrospectively reviewed to determine the primary diagnosis, surgery indication, and cause of readmission and return to operating room. The cost for index hospitalization, readmission episode, and total cost were derived based on the charges obtained from administrative data. Bivariate and multivariable analyses were conducted. RESULTS Of 536 patients readmitted in total, 17.9% (n = 96) were readmitted within 90 days. Of the overall readmissions, 11.9% (n = 64) were readmitted within 30 days, and 5.97% (n = 32) were readmitted between 31 and 90 days. The median duration between discharge and readmission was 20 days (first quartile [Q1]: 9 days, third quartile [Q3]: 36 days). The most common reason for readmission was shunt related (8.2%, n = 44), followed by wound infection (4.7%, n = 25). In the risk-adjusted multivariable logistic regression model for total 90-day readmission, patients with the following characteristics: younger age (p = 0.001, OR 0.886, 95% CI 0.824-0.952); "other" (nonwhite, nonblack) race (p = 0.024, OR 5.49, 95% CI 1.246-24.2); and those born preterm (p = 0.032, OR 2.1, 95% CI 1.1-4.12) had higher odds of being readmitted within 90 days after discharge. The total median cost for patients undergoing surgery in this study cohort was $11,520 (Q1: $7103, Q3: $19,264). For the patients who were readmitted, the median cost for a readmission episode was $8981 (Q1: $5051, Q3: $18,713). CONCLUSIONS Unplanned 90-day readmissions in pediatric neurosurgery are primarily due to CSF-related complications. Patients with the following characteristics: young age at presentation; "other" race; and children born preterm have a higher likelihood of being readmitted within 90 days after surgery. The median cost was > $8000, which suggests that the readmission episode can be as expensive as the index hospitalization. Clearly, readmission reduction has the potential for significant cost savings in pediatric neurosurgery. Future efforts, such as targeted education related to complication signs, should be considered in the attempt to reduce unplanned events. Given the single-center, retrospective study design, the results of this study are primarily applicable to this population and cannot necessarily be generalized to other institutions without further study.

90-day Readmission After Lumbar Spinal Fusion Surgery in New York State Between 2005 and 2014: A 10-year Analysis of a Statewide Cohort

MINI: We assessed 90-day readmission and evaluated risk factors associated with readmission after lumbar spinal fusion surgery in New York State. The overall 90-day readmission rate was 24.8%. Age, sex, race, insurance, procedure, number of operated spinal levels, health service area, and comorbidities are major risk factors for 90-day readmission.

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to assess 90-day readmission and evaluate risk factors associated with readmission after lumbar fusion in New York State.

SUMMARY OF BACKGROUND DATA

Readmission is becoming an important metric for quality and efficiency of health care. Readmission and its predictors following spine surgery are overall poorly understood and limited evidence is available specifically in lumbar fusion.

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) was utilized to capture patients undergoing lumbar fusion from 2005 to 2014. Temporal trend of 90-day readmission was assessed using Cochran-Armitage test. Logistic regression was used to examine predictors associated with 90-day readmission.

RESULTS

There were 86,869 patients included in this cohort study. The overall 90-day readmission rate was 24.8%. On a multivariable analysis model, age (odds ratio [OR] comparing ≥75 versus <35 years: 1.24, 95% confidence interval [CI]: 1.13-1.35), sex (OR female to male: 1.19, 95% CI: 1.15-1.23), race (OR African-American to white: 1.60, 95% CI: 1.52-1.69), insurance (OR Medicaid to Medicare: 1.42, 95% CI: 1.33-1.53), procedure (OR comparing thoracolumbar fusion, combined [International Classification of Disease, Ninth Revision, ICD-9: 81.04] to posterior lumbar interbody fusion/transforaminal lumbar spinal fusion [ICD-9: 81.08]: 2.10, 95% CI: 1.49-2.97), number of operated spinal levels (OR comparing four to eight vertebrae to two to three vertebrae: 2.39, 95% CI: 2.07-2.77), health service area ([HSA]; OR comparing Finger Lakes to New York-Pennsylvania border: 0.67, 95% CI: 0.61-0.73), and comorbidity, i.e., coronary artery disease (OR: 1.26, 95% CI: 1.19-1.33) were significantly associated with 90-day readmission. Directions of the odds ratios for these factors were consistent after stratification by procedure type.

CONCLUSION

Age, sex, race, insurance, procedure, number of operated spinal levels, HSA, and comorbidities are major risk factors for 90-day readmission. Our study allows risk calculation to determine high-risk patients before undergoing spinal fusion surgery to prevent early readmission, improve quality of care, and reduce health care expenditures.

LEVEL OF EVIDENCE

3.

Complication Rates After Bone Morphogenetic Protein (BMP) Use in Orthopaedic Surgery in Children: A Concise Multicenter Retrospective Cohort Study

BACKGROUND

The use of bone morphogenetic protein (BMP) has been associated with a number of complications in adult patients. However, this association is less established in children. The aim of this study was to evaluate the safety of BMP use in children by determining the complication rates after BMP use at multiple institutions.

METHODS

In a retrospective study (2000 to 2013), the medical records of all patients who received BMP at any of the 5 institutions were reviewed. Demographic information, preoperative data, and postoperative follow-up data were collected on those patients who were under the age of 18 at the time of surgery.

RESULTS

A total of 312 pediatric patients underwent surgery with BMP application during the study period. The surgical procedures consisted of 228 spinal fusions, 39 pars repairs, 33 nonunion repair, and 12 other various procedures. Overall 21% (65/312) of patients who had BMP utilized had a complication. Fifty-five percent (36/65) of patients with a complication required a revision surgery. The average follow-up was 27 months (range, 3 to 96 mo); 80% of patients had a follow-up period of >12 months. The average age at the time of surgery was 13 years (range, 1 to 17 y). Males and females were almost equally represented in the study: 143 males (46%) and 168 females (54%). Of the patients who received BMP, 9% had minor complications and 13% had major complications. Wound dehiscence without infection was the most common minor complication and occurred in 59% (16/27) of patients with minor complications. Infection and implant failures were the most frequent major complications, occurring in 38% (15/39) and 33% (13/39) of patients with major complications, respectively. Five of 312 (2%) patients had neurological injury, 3 of which were only temporary.

CONCLUSIONS

This multicenter study demonstrates a relatively high rate of complications after the use of BMP in children. However, further study is needed to attribute the complications directly to the use of BMP.

LEVEL OF EVIDENCE

Level IV.

Seasonal Variations in the Risk of Reoperation for Surgical Site Infection Following Elective Spinal Fusion Surgery: A Retrospective Study Using the Japanese Diagnosis Procedure Combination Database

STUDY DESIGN

A retrospective study of data abstracted from the Diagnosis Procedure Combination (DPC) database, a national representative database in Japan.

OBJECTIVE

The aim of this study was to examine seasonal variations in the risk of reoperation for surgical site infection (SSI) following spinal fusion surgery.

SUMMARY OF BACKGROUND DATA

Although higher rates of infection in the summer than in other seasons were thought to be caused by increasing inexperience of new staff, high temperature, and high humidity, no studies have examined seasonal variations in the risk of SSI following spinal fusion surgery in the country where medical staff rotation timing is not in summer season. In Japan, medical staff rotation starts in April.

METHODS

We retrospectively extracted the data of patients who were admitted between July 2010 and March 2013 from the DPC database. Patients were included if they were aged 20 years or older and underwent elective spinal fusion surgery. The primary outcome was reoperation for SSI during hospitalization. We performed multivariate analysis to clarify the risk factors of primary outcome with adjustment for patient background characteristics.

RESULTS

We identified 47,252 eligible patients (23,659 male, 23,593 female). The mean age of the patients was 65.4 years (range, 20-101 yrs). Overall, reoperation for SSI occurred in 0.93% of the patients during hospitalization. The risk of reoperation for SSI was significantly higher in April (vs. February; odds ratio, 1.93; 95% confidence interval, 1.09-3.43, P = 0.03) as well as other known risk factors. In subgroup analysis with stratification for type of hospital, month of surgery was identified as an independent risk factor of reoperation for SSI among cases in an academic hospital, although there was no seasonal variation among those in a nonacademic hospital.

CONCLUSION

This study showed that month of surgery is a risk factor of reoperation for SSI following elective spinal fusion surgery, nevertheless, in the country where medical staff rotation timing is not in summer season.

LEVEL OF EVIDENCE

3.

Analysis of risk factors associated with unplanned reoperations following pediatric plastic surgery

BACKGROUND/PURPOSE

Unplanned reoperation (UR) is an outcome measure with multiple advantages that can be used as a standardized tool to assess an institution's quality and safety of medical care. This study aimed to identify parameters associated with an increased likelihood of UR following plastic surgery in patients less than 18 years of age by using a large validated national multicenter database.

METHODS/DESCRIPTION

We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database between 2012 and 2014 to identify pediatric patients undergoing primary plastic surgery procedures. Two cohorts were compared: patients who experienced UR and those who did not. Multiple logistic regression analysis was utilized to identify independent risk factors associated with UR.

RESULTS

A total of 18,106 patients were identified in this analysis, with an overall UR rate of 0.8% (n = 137) within 30 days after surgery. Patients were on average 5.59 ± 5.27 years of age with 9522 boys (52.6%) and 8584 girls (47.4%). The procedures most commonly associated with UR were excision of skin and subcutaneous tissue for hidradenitis (UR = 10.3%), forehead, and/or supraorbital rim reconstruction with grafts (allograft or prosthetic material, UR = 6.1%), use of multiplane external fixators (UR = 5.6%), mastectomy for gynecomastia (UR = 4.4%), and forehead and/or supraorbital rim reconstruction with autograft (3.3%). The average number of relative value units per case was 10.01 ± 7.91. Independent risk factors for UR include inpatient procedure (p < 0.001), ASA class 3 or higher (p = 0.03), prolonged operative time (p < 0.001), and prior open wound or wound infection (p = 0.05). The most significant predictors of UR were postoperative medical and surgical complications (OR, 18.92 and 39.98, respectively, p < 0.001).

CONCLUSIONS

With increasing focus on outcomes-driven healthcare, unplanned reoperation may be useful for monitoring quality across hospitals and identifying opportunities for quality improvement. This study provides the first analysis of risk factors associated with 30-day unplanned reoperations in pediatric plastic surgery. These results may aid in the informed consent process, improve patient risk assessment, counseling, and surgical planning.